Provider Demographics
NPI:1700215654
Name:MATHEW, KENDALL (LMP)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28129 239TH PL SE
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-5123
Mailing Address - Country:US
Mailing Address - Phone:425-432-4787
Mailing Address - Fax:
Practice Address - Street 1:28129 239TH PL SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-5123
Practice Address - Country:US
Practice Address - Phone:425-432-4787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60390830225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist